Complex Care Presentation

COMPLEX CARE
-SUBMITTED BY:

PRESENTING COMPLAINT:
 Rachel presented to the outpatient department with severe
chest pain and a pounding sensation in the chest, neck and
ears
 She reports feeling fatigued and experiencing burning
sensation in her feet
 Vitals assessment:
Temp: 101̊ ̊ F, Respiratory Rate: 28 breaths per minute, BP:
140/90, Pulse: 102 beats per minute
Body Weight: 174 pounds

Medical History:
 Rachel has a medical history of Type II Diabetes since the previous 6
years
 Her current medication include:
 Metformin 500 mg PO
 Lisinopril 20 mg orally once a day
 No reported allergies

Psychosocial History:
 Suffered from depression because of bullying at school at the age of 14
years
 Does not stay with parents but shares a good relation
 Has recently gone through a bad breakup
 Reports not indulging in social interaction for the far of being bullied
because of her weight
 Relies heavily upon take away meals
 Worked at a salon but had to quit because of her increased health
complications and at present sustains on her savings